WO1995004509A1 - Procede de photoablation au laser de tissu du cristallin - Google Patents

Procede de photoablation au laser de tissu du cristallin Download PDF

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Publication number
WO1995004509A1
WO1995004509A1 PCT/US1994/008835 US9408835W WO9504509A1 WO 1995004509 A1 WO1995004509 A1 WO 1995004509A1 US 9408835 W US9408835 W US 9408835W WO 9504509 A1 WO9504509 A1 WO 9504509A1
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Prior art keywords
laser
lens
tissue
laser beam
ocular lens
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PCT/US1994/008835
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English (en)
Inventor
Arlene E. Gwon
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Gwon Arlene E
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Publication of WO1995004509A1 publication Critical patent/WO1995004509A1/fr

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    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61F—FILTERS IMPLANTABLE INTO BLOOD VESSELS; PROSTHESES; DEVICES PROVIDING PATENCY TO, OR PREVENTING COLLAPSING OF, TUBULAR STRUCTURES OF THE BODY, e.g. STENTS; ORTHOPAEDIC, NURSING OR CONTRACEPTIVE DEVICES; FOMENTATION; TREATMENT OR PROTECTION OF EYES OR EARS; BANDAGES, DRESSINGS OR ABSORBENT PADS; FIRST-AID KITS
    • A61F9/00—Methods or devices for treatment of the eyes; Devices for putting-in contact lenses; Devices to correct squinting; Apparatus to guide the blind; Protective devices for the eyes, carried on the body or in the hand
    • A61F9/007—Methods or devices for eye surgery
    • A61F9/008—Methods or devices for eye surgery using laser
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61F—FILTERS IMPLANTABLE INTO BLOOD VESSELS; PROSTHESES; DEVICES PROVIDING PATENCY TO, OR PREVENTING COLLAPSING OF, TUBULAR STRUCTURES OF THE BODY, e.g. STENTS; ORTHOPAEDIC, NURSING OR CONTRACEPTIVE DEVICES; FOMENTATION; TREATMENT OR PROTECTION OF EYES OR EARS; BANDAGES, DRESSINGS OR ABSORBENT PADS; FIRST-AID KITS
    • A61F9/00—Methods or devices for treatment of the eyes; Devices for putting-in contact lenses; Devices to correct squinting; Apparatus to guide the blind; Protective devices for the eyes, carried on the body or in the hand
    • A61F9/007—Methods or devices for eye surgery
    • A61F9/008—Methods or devices for eye surgery using laser
    • A61F9/00802—Methods or devices for eye surgery using laser for photoablation
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61F—FILTERS IMPLANTABLE INTO BLOOD VESSELS; PROSTHESES; DEVICES PROVIDING PATENCY TO, OR PREVENTING COLLAPSING OF, TUBULAR STRUCTURES OF THE BODY, e.g. STENTS; ORTHOPAEDIC, NURSING OR CONTRACEPTIVE DEVICES; FOMENTATION; TREATMENT OR PROTECTION OF EYES OR EARS; BANDAGES, DRESSINGS OR ABSORBENT PADS; FIRST-AID KITS
    • A61F9/00—Methods or devices for treatment of the eyes; Devices for putting-in contact lenses; Devices to correct squinting; Apparatus to guide the blind; Protective devices for the eyes, carried on the body or in the hand
    • A61F9/007—Methods or devices for eye surgery
    • A61F9/008—Methods or devices for eye surgery using laser
    • A61F2009/00853—Laser thermal keratoplasty or radial keratotomy
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61F—FILTERS IMPLANTABLE INTO BLOOD VESSELS; PROSTHESES; DEVICES PROVIDING PATENCY TO, OR PREVENTING COLLAPSING OF, TUBULAR STRUCTURES OF THE BODY, e.g. STENTS; ORTHOPAEDIC, NURSING OR CONTRACEPTIVE DEVICES; FOMENTATION; TREATMENT OR PROTECTION OF EYES OR EARS; BANDAGES, DRESSINGS OR ABSORBENT PADS; FIRST-AID KITS
    • A61F9/00—Methods or devices for treatment of the eyes; Devices for putting-in contact lenses; Devices to correct squinting; Apparatus to guide the blind; Protective devices for the eyes, carried on the body or in the hand
    • A61F9/007—Methods or devices for eye surgery
    • A61F9/008—Methods or devices for eye surgery using laser
    • A61F2009/00861—Methods or devices for eye surgery using laser adapted for treatment at a particular location
    • A61F2009/0087—Lens
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61F—FILTERS IMPLANTABLE INTO BLOOD VESSELS; PROSTHESES; DEVICES PROVIDING PATENCY TO, OR PREVENTING COLLAPSING OF, TUBULAR STRUCTURES OF THE BODY, e.g. STENTS; ORTHOPAEDIC, NURSING OR CONTRACEPTIVE DEVICES; FOMENTATION; TREATMENT OR PROTECTION OF EYES OR EARS; BANDAGES, DRESSINGS OR ABSORBENT PADS; FIRST-AID KITS
    • A61F9/00—Methods or devices for treatment of the eyes; Devices for putting-in contact lenses; Devices to correct squinting; Apparatus to guide the blind; Protective devices for the eyes, carried on the body or in the hand
    • A61F9/007—Methods or devices for eye surgery
    • A61F9/008—Methods or devices for eye surgery using laser
    • A61F2009/00885—Methods or devices for eye surgery using laser for treating a particular disease
    • A61F2009/00887—Cataract
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61F—FILTERS IMPLANTABLE INTO BLOOD VESSELS; PROSTHESES; DEVICES PROVIDING PATENCY TO, OR PREVENTING COLLAPSING OF, TUBULAR STRUCTURES OF THE BODY, e.g. STENTS; ORTHOPAEDIC, NURSING OR CONTRACEPTIVE DEVICES; FOMENTATION; TREATMENT OR PROTECTION OF EYES OR EARS; BANDAGES, DRESSINGS OR ABSORBENT PADS; FIRST-AID KITS
    • A61F9/00—Methods or devices for treatment of the eyes; Devices for putting-in contact lenses; Devices to correct squinting; Apparatus to guide the blind; Protective devices for the eyes, carried on the body or in the hand
    • A61F9/007—Methods or devices for eye surgery
    • A61F9/008—Methods or devices for eye surgery using laser
    • A61F2009/00885—Methods or devices for eye surgery using laser for treating a particular disease
    • A61F2009/00895—Presbyopia
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61F—FILTERS IMPLANTABLE INTO BLOOD VESSELS; PROSTHESES; DEVICES PROVIDING PATENCY TO, OR PREVENTING COLLAPSING OF, TUBULAR STRUCTURES OF THE BODY, e.g. STENTS; ORTHOPAEDIC, NURSING OR CONTRACEPTIVE DEVICES; FOMENTATION; TREATMENT OR PROTECTION OF EYES OR EARS; BANDAGES, DRESSINGS OR ABSORBENT PADS; FIRST-AID KITS
    • A61F9/00—Methods or devices for treatment of the eyes; Devices for putting-in contact lenses; Devices to correct squinting; Apparatus to guide the blind; Protective devices for the eyes, carried on the body or in the hand
    • A61F9/007—Methods or devices for eye surgery
    • A61F9/00736—Instruments for removal of intra-ocular material or intra-ocular injection, e.g. cataract instruments

Definitions

  • the present invention relates generally to the field of photoablation of ocular tissue to correct vision deficiencies and treat other vision-impairing ocular problems and, more particularly, to treatment of the natural ocular lens .
  • eyeglasses i.e., spectacles
  • eyeglasses were exclusively used for most correctable vision deficiencies, including, for example, hyperopia (wherein incident parallel rays of light converge to focus behind the retina) , myopia (wherein incident parallel rays of light converge to a focus in front of the retina) , and astigmatism (a defect in vision ordinarily caused by irregularities in the cornea) .
  • contact lens started being used as a viable alternative, at least for many individuals, to the use of spectacles for correcting vision deficiencies, and provided— often at a cost of some discomfort—freedom from many annoyances and appearance problems associated with the wearing of spectacles.
  • radial keratotomy a surgical procedure on the cornea called radial keratotomy (RK) .
  • RK radial keratotomy
  • slits for example, about four to about eight
  • radial slits enable the cornea to flatten out a bit, thereby decreasing the curvature of the cornea.
  • Candidates for RK procedures are typically nearsighted individuals who cannot or who do not want to wear either spectacles or contact lenses.
  • Corneal onlays or implants which may be constructed of synthetic materials or from donor corneas, which are surgically attached to or implanted into patients' eyes, are also useful to enhance vision in patients whose corneas have been damaged and/or scarred by corneal diseases, such as ulcers or cancer, or by injury to the cornea.
  • Excimer lasers lasers operating in the ultraviolet (UV) region of less than about 200 nanometers wavelength—have thus now been used to selectively ablate regions of the cornea to resculpture the corneas of patients in a manner correcting certain vision problems. For example, regions of the cornea around its optical axis are photoablated to a greater depth than peripheral regions of the ' cornea, thereby decreasing the curvature of the cornea to correct myopia.
  • UV ultraviolet
  • U.S. Patent No. 4,784,135 to Blum et al. discloses a method for removing biological tissue * by irradiation of the tissue with UV radiation while, for example, U.S. Patent Nos. 4,665,913; 4,669,466; 4,718,418; 4,721,379; 4,729,372;
  • L'Esperance disclose apparatus and methods for laser sculpting of corneal tissue to correct vision defects.
  • U.S. Patent No. 4,842,782 to Portney et al. and No. 4,856,513 to Muller disclose masks useful for selectively controlling the laser beam intensity or total laser beam energy to different regions to thereby enable selective corneal ablation to effect the desired vision correction.
  • Various of the above-cited patents to L'Esperance also disclose methods for determining the required laser ablation profile for the cornea.
  • Patent No. 4,995,923 discloses computer mapping of the cornea and computer-controlled scanning of the cornea by the laser beam.
  • the cornea is sculpted in a manner correcting vision, it is frequently the case that the cornea itself is not responsible for the vision problems being corrected.
  • myopia may more likely be caused by an increase in lens size, usually as a natural effect of the human aging process, of the •natural lens of the eye (located posteriorly of the cornea) .
  • Other vision defects or deficiencies may also originate at the natural lens, while the associated cornea may itself be in a normal condition.
  • the present inventor has determined that it would often be preferable to reprofile the natural lens over reprofiling the cornea.
  • Such natural lens reprofiling would eliminate many of the concerns presently raised about corneal photoablation and may result in reduced risks to patients; and since the lens has no nerve supply, the procedure should result in no sensation of pain to the patient.
  • a principal objective of the present invention to provide a method for laser ablation of selected regions of the natural lens in order to correct vision problems and to correct problems, such as incipient cataract, on the lens.
  • a method for the laser photoablation of ocular lens tissue comprising the steps of determining the volume of the lens tissue to be photoablated and directing a pulsed laser beam at such volume with an amount of energy effective for photoablating the region without causing substantial damage to the surrounding tissue regions.
  • an alternative embodiment of the present invention includes the initiation of photoablation of the surface of the the ocular lens anterior surface and thereafter moving the focal point inwardly and away from the anterior surface in order to promote the absorption of laser by products by adjacent healthy tissue.
  • a laser suitable for use in the present invention may be an Nd:YLF laser having an operating frequency in the infrared spectrum and more preferably having an operating frequency of about 1053 nanometers.
  • the laser preferably has a repetition rate of between about 1 and about 1000 Hertz, and more preferably about 1000 Hertz, and operates with a pulse width of between about 1 femtosecond and about 1 millisecond and, more preferably, about 60 picoseconds.
  • the laser preferably may operate at an energy level of between about 1 nanojoule and about 50 millijoules per pulse and, more preferably, about 30 microjoules. Still further, the laser preferably operates with a beam spot diameter of between about 1 micron and about 100 microns and, more preferably, with a beam spot diameter of about 20 microns.
  • the laser preferably operates with a zone of effect of less than about 200 microns and, more preferably, with a zone of effect of less than about 50 microns.
  • a method for the laser photoablation of ocular lens tissue for the correction of myopia, hyperopia, or presbyopia.
  • the method comprises the steps of determining the region of the lens tissue to be photoablated, calculating the amount of lens tissue to be photoablated from the determined region, and directing the pulsed infrared laser beam at the region with an amount of energy effective for photoablating the calculated amount of lens tissue in the determined region without causing substantial damage to lens tissue surrounding such region.
  • a method for the laser photoablation of ocular lens tissue for the removal of incipient cataract comprising the steps of determining the region of the lens tissue to be photoablated so as to remove the incipient cataract, calculating the amount of lens tissue to be photoablated from the determined region so as to remove the incipient cataract; and directing the pulsed infrared laser beam at the region with an amount of energy effective for photoablating the calculated amount of lens tissue in the determined region so as to remove the incipient cataract without causing substantial damage to lens tissue surrounding such region.
  • Figure 1 is a longitudinal cross sectional drawing of a representative eye showing, in simplified form, the cornea, iris, natural lens and retina, and showing the manner in which an image is focused on the retina in a normal eye.
  • Figure 2 is an enlarged, longitudinal cross sectional drawing of a normal lens showing, in simplified form, its composition;
  • Figure 3 is a simplified, longitudinal cross sectional drawing—similar to Figure 1—showing the manner in which the natural lens has regions thereof photoablated using, for example, an Nd:YLF laser operating at a frequency of about 1053 nanometers and operating at a repetition rate of about 1000 pulses per second; Figure 3a showing the manner in which internal regions of the lens are photoablated for the purpose of correcting myopia, hyperopia or presbyopia; and Figure 3b showing the manner in which generally surface and subsurface regions of the lens are photoablated to remove incipient cataract.
  • Nd:YLF laser operating at a frequency of about 1053 nanometers and operating at a repetition rate of about 1000 pulses per second
  • Figure 3a showing the manner in which internal regions of the lens are photoablated for the purpose of correcting myopia, hyperopia or presbyopia
  • Figure 3b showing the manner in which generally surface and subsurface regions of the lens are photoablated to remove incipient cataract.
  • Figure 1 a longitudinal cross sectional drawing of a typical normal eye, which is generally symmetrical about an optical axis 12. Shown comprising the eye and in order from the front of the eye to the back are a cornea 14, an iris 16, a natural lens 18 and a retina 20.
  • a cornea 14 Shown comprising the eye and in order from the front of the eye to the back are a cornea 14, an iris 16, a natural lens 18 and a retina 20.
  • a cornea 14 and lens 18 Shown a cornea 14, an iris 16, a natural lens 18 and a retina 20.
  • image 24 on retina 20
  • iris 16 being shown as having an open central aperture 26 permitting light to pass through to the lens
  • lens 18 is a biconvex, somewhat flexible structure which is suspended behind iris 16 and is connected to a peripheral ciliary body 30 of the eye by zonal fibers (zonules) 32. Since lens 18 is avascular, its pathology is more simple than most other tissues of the body; primary inflammation processes do not occur and neoplastic growths in lens 18 are unknown. However, trauma or injury to lens 18 results in passive and degenerative changes in the lens with consequent opacification.
  • Focusing of lens 18, which functions to transmit and refract light to retina 20, is (assuming the lens is in its normal, youthful condition) by contraction and relaxation of zonal fibers 32.
  • lens 18 assumes its maximum convex curvature and thickness; as tension in zonal fibers increases, lens 18 is stretched and its convex curvature and thickness are decreased.
  • accommodation the shape of lens 18 is physically varied in a manner causing images 22 to be correctly focused on retina 20 as the distance D between object 22 and cornea 14 changes between far and near.
  • Lens 18 consists of about 65% water and about 35% protein (known as crystalline) , along with traces of minerals.
  • Lens 18 is avascular, containing no blood vessels, and has no nerve supply, and comprises a thin, transparent capsule or bag 34, a subcapsular epithelium layer 36, a cortex 38 of soft fibers and a harder, dense nucleus 40 at the center.
  • surface ectoderm invaginates to form the lens vesicle.
  • the posterior cells of the lens vesicle then elongate to form the primary lens fibers, which obliterate the cavity of the vesicle and abut on the anterior (forward) epithelium layer 36. This process is completed early in fetal development.
  • Lens 18 continues to grow throughout an individual's life in a process similar to that in which the epidermal tissue of the skin renews itself. However, unlike the skin where old cells are continu ⁇ ally cast off from the surface, older lens cells accu ⁇ mulate centrally and cannot be cast off. The net result is progressive growth of lens 18 with age, associated with a decrease in elasticity and accommo ⁇ dative ability. The result is that the most common degenerative condition of lens 18 is presbyopia, a condition in which loss of elasticity of the lens results in the inability of the eye to focus sharply for near vision, such that most individuals by about the age of forty require some visual assistance, for example, that provided by spectacles, contact lenses or RK surgery.
  • cataract Another common degenerative condition of lens 18 that is generally associated with aging is cataract, which is generally defined as any opacity in the lens. In the case of cataract, the extent of disability depends upon the location and severity of the opacity.
  • a relatively small posterior (i.e., rearward) subcapsular cataract may be visually incapacitating because it is situated near the nodal point of the dioptric system, while peripheral opacities that do not impinge on optical axis 12 may cause little visual inconvenience.
  • patients initially complain of a visual disturbance, then a diminution of vision, and finally a complete failure of vision ' .
  • therapeutic modality i.e., treatment
  • Ophthalmologists have long considered removal of lens 18 as the only treatment for cataract.
  • the most commonly performed operation is an extracapsular cataract extraction with intraocular lens implantation, the objective of the surgical procedure being to remove as much of the lens as possible with subsequent optical device correction.
  • the concept of selective removal of a small opacity or sections of the lens was not heretofore considered nor would it have been technically possible.
  • the present invention relates to methods to treat presbyopia, refractive errors, and cataract by means of focusing high.power pulse laser photoablation of lens opacities and selected normal lens fibers.
  • a laser 50 ( Figure 3) which can advantageously be used for such purpose is preferably, but is not limited to, a quasi-continuous Nd:YLF picosecond laser which may be purchased as ISL Model 2001 MPL or 4001 CLS from Intelligent Laser Systems, Inc. of San Diego, California.
  • laser 50 produces a shock wave in the tissue at which its beam is focused, the shock wave expanding radially from the point of focus and disintegrating the target tissue (optical break ⁇ down) , thereby causing ionization of the medium and the formation of a plasma.
  • This plasma is a gaseous state, formed when electrons are stripped away from their atoms in either a gas, liquid or solid. Once optical breakdown occurs, the plasma that is formed absorbs or scatters subsequent light in the laser pulse, thereby acting as an effective shield protecting underlying structures. The quicker the laser pulses, the faster and more easily the plasma is created.
  • laser 50 preferably has the following characteristics:
  • An operating frequency preferably in the visible and infrared (IR) spectrum; more preferably, about 1053 nanometers (nm) ;
  • a repetition rate preferably ranging from about one to about 1000 Hertz; more preferably, about 1000 pulses per second; (3) A pulse width preferably ranging from about 1 femtosecond to about 1 millisecond; more preferably, about 60 picoseconds;
  • An energy level per pulse preferably ranging from about 1 nanojoule to about 50 millijoules;. more preferably, about 60-140 microjoules.
  • a focused spot size preferably between about 1 micron and about 100 microns; more preferably, about 20 microns.
  • a "zone of effect” preferably limited to between about 1 and about 200 microns with little collateral effect; more preferably, the zone of effect is limited to about 50 microns.
  • the procedure described hereinbelow for the laser photoablation of lens tissue ordinarily requires an initial ocular examination of the prospective patient, including refractive status, slit lamp biomicroscopy, and the measurement of axial length of lens 18 by standard applanation A-scan ultrasonography.
  • the accommodative amplitude of lens 18 may be measured by various techniques.
  • the convex lens is then reduced (to a concave lens) , or, alternatively, the target object is brought closer to the patient's eye until the target again starts to blur.
  • the range between the "far" blur and the "near” blur or maximum plus (convex lens) to blur and maximum minus (concave lens) to blur is the range of accommodation in diopters.
  • the amount of lens thickness to be ablated can be calculated in two ways:
  • the amount of required lens tissue ablation is calculated by subtracting the desired accommodation amplitude from the patient's actual accommodation amplitude.
  • a patient of age 60 has a lens thickness of 4.66 mm and an accommodation amplitude of 1.25 diopters.
  • about .51 mm (4.66 mm minus 4.15 mm) of lens tissue is preferably removed from the patient's lens.
  • the amount of lens tissue to be ablated is calculated based on the work of Koretz and Handelman (Koretz, J.F., Handelman, G.H. , "Model of the accommodation mechanism in the human eye,” Vision Res . , Vol. 22, 1982:917-927—which is incorporated hereinto by specific reference) .
  • a two-micron change in lens thickness corresponds to a 0.02 diopter change in accommodation.
  • the amount of decrease in lens thick ⁇ ness required would be approximately 375 microns.
  • the amount of lens tissue to be ablated is calculated as described above for presbyopia. This will increase the ampli ⁇ tude of accommodation of the patient's lens to allow the hyperope to move the focus of distant objects up to his or her retina 20.
  • the amount of lens tissue to be ablated can be calculated based on the refractive status of the eye and the measured lens thickness as set forth above in Paragraph (2) .
  • a beam 52 from an HeNe focusing laser 54 (Figure 3a)is focused, by an associated lens or lens system 56, through cornea 14 (which is transparent to the focusing beam) and iris opening 26, to a region 56 to be photoablated by Nd:YLF laser 50 for correction of the specific vision problem under treatment.
  • Nd:YLF laser 50 for correction of the specific vision problem under treatment.
  • a laser beam 60 from Nd:YLF laser 50 is focused by an associated focusing lens or lens system 62 through cornea 14 (which is transparent to the laser beam) and iris opening 26, onto region 56 which is to be photoablated by the Nd:YLF laser beam.
  • the amount of lens tissue to be ablated (i.e., decomposed) to achieve the desired vision correction is determined in the manner described above.
  • the optical zone (equatorial diameter) should be approximately equal to the diameter of nucleus 40 and the axial width (for example, about 510 microns) .
  • region 56 be selected so that nucleus 40 and/or centrally located older fibers in cortex 38 are ablated using a smaller optical zone so as to decrease the curvature of an anterior (forward) surface 62 of lens 18.
  • Such laser ablation of lens 18 to correct myopia, presbyopia and hyperopia may be termed "photorefractive phacoplasty” or "phototherapeutic phacoplasty".
  • beam 52 from HeNe focusing laser 54 ( Figure 3) may be directly focused by lens or lens system 56 (with the beam passing through cornea 14 and iris opening 26) onto an area or region 64 of small lenticular opacity.
  • beam 60 from Nd:YLF laser 50 is focused, by lens or lens system 62 onto area or region 64 and the laser is pulsed until the opacity is ablated (as determined, for example, by visual observation through cornea 12 and iris opening 26) .
  • opacity area or region 64 is adjacent to lens capsule 18 ( Figure 2) , aiming beam 52 from HeNe laser 52 is focused more centrally to the opacity to account for shock wave expansion.
  • Such treatment i.e., photoablative removal
  • phototherapeutic phacoablation or "photo-therapeutic phacoectomy”.
  • the method includes initiating photoablation at the surface of the ocular tissue and thereafter the point of photoablation is moved inwardly, or away, from the anterior ocular surface.
  • Nd:YLF laser 50 Care is taken in the operation of Nd:YLF laser 50 not to rupture lens capsule 34 by expansion of laser shock wave. Moreover, if excessive bubbles are formed at the ablation site, as detected, for example, by viewing, with a slit lamp (not shown) the ablation region through cornea 14 and iris opening 26, the laser ablation procedure is discontinued and addi ⁇ tional treatment is performed at a later date, for example, in one or two weeks.
  • the natural lens in an eye can be photoablated by pulsed energy from a laser—preferably an Nd:YLF laser—in a manner cor ⁇ recting myopia, presbyopia and hyperopia and in a manner removing incipient cataracts.
  • a laser preferably an Nd:YLF laser
  • a traumatic anterior cortical cataract was produced in the right eye during a corneal wound healing experiment.
  • a 2 mm full thickness trephine cut was made in the central cornea with a disposable biopsy punch (Acuderm Inc. , Ft. Lauderdale, Florida) .
  • the corneal perforation was sealed with a collagen patch and the anterior capsular tear was sealed by the rabbit's natural fibrin reaction.
  • the anterior cortical cataract remained localized and moved more central in location as newer lens cortical fibers separated the cortical opacity from the anterior capsular scar over time.
  • the anterior cortical opacity remained localized for one year prior to laser treatment.
  • the eye to be operated on was dilated with 1% cyclopentolate (Alcon, Fort Worth, Texas) and 10% phenylephrine (Winthrop, New York, New York) . Animals were anesthetized as mentioned above. A wire lid speculum was inserted to retract the lids, and the eye with the cataract was placed in position at the slit lamp laser.
  • HeNe aiming beam was used to deliver 697 spots of 2- 8.3 millijoules of energy/pulse with a 50 micron spot size to the anterior cortex or nucleus of a normal lens of six NZA rabbits.
  • An infrared picosecond laser with an HeNe aiming beam (Nd:YLF laser, ISL, San Diego, California) was used to deliver 60-140 microjoules of energy/pulse with a 0.3-0.6 mm 3 cube at 1053 nm to one normal lens and three cataractous opacities in three rabbits.
  • the first rabbit received one treatment.
  • the second rabbit was treated three times and the third rabbit five times.
  • the single treatment consisted of single spots and monolayers whereas all other treatments used three-dimensional patterns.
  • the program of the laser was set so that the plasma would destroy first the deeper parts of the opacity and then work forward to the anterior part. This procedure was chosen in order to bring the plasma away from the delicate posterior capsule as fast as possible.
  • the ISL Model 2001 MPL Nd:YLF laser (ISL, San Diego, CA) is an infrared laser (1053 nm) , operating in the picosecond domain.
  • infrared light is not absorbed strongly by the transparent media of the eye.
  • the laser beam is focused to the area where ablation is intended to occur. Areas as small as 1 ⁇ can be ablated by direct microplasma-induction on one hand and by microplasma- induced shock wave on the other hand.
  • the energy necessary to create a plasma in the picosecond domain (60-90 microjoules) is considerably smaller than in the nanosecond domain (1-3 millijoules) .
  • the collateral damage to the surrounding tissue is due to the cavitation bubble and the shock wave effect is much smaller. Theoretically, this gives the picosecond laser the capability to operate closer to delicate structure than is possible with the nanosecond laser.
  • the ISL 2001 has a repetition rate of 1 kHz (1000 Hz) which gives it the capability of reasonable tissue ablation rates per time unit.
  • mice Postoperatively, animals were examined daily for one week, weekly for one month, and monthly thereafter by slit lamp biomicroscopy and photography with pupil dilation using 1% Mydiacyl (Alcon Laboratories, Fort Worth, Texas) .
  • single 50 micron spot laser pulses of 2-8.3 millijoules/pulse produced gaseous bubble formation in the normal lens which resolved within 24 hours.
  • small ring-like opacities were noted in the area of the original laser spot treatment, in some areas, a faint halo/haze was noted to surround the ring opacity.
  • the halo was noted to be more prominent in the superficial anterior cortex and the nucleus, absent in the deeper cortical regions and tended to fade by 3 months.
  • the pinpoint opacities remained throughout the one year follow-up time.
  • the anterior cortical and posterior subcapsular opacities appeared less dense and stabilized by 48 hours. After repetitive treatment, the lens opacities gained additional transparency but the beneficial effects decreased slightly after the third treatment.
  • the area of direct laser treatment appeared to be clearer while the lens opacities appeared to thin and expand as if the lenticular fibers were contracting peripherally. However, there was no evidence of any increase in opacification in any of the treated eyes.
  • the ocular lens is a unique organ in its derivation from one cell type, retention throughout life of all cells that are ever produced, in having no blood or nerve supply and in synthesizing unique proteins.
  • inflammatory process do not occur and trauma or insult generally results in passive and degenerative changes in the lens with consequent opacification.
  • the present example shows that focal laser ablation of the normal lens with the Nd:YLF laser selectively removed a part of the lens while retaining its structure and function, and without resulting in irreversible damage/opacification.
  • cataract may be reversed, arrested and perhaps ablated. These include the reversibility of galacto- semic cataract by a lactose-free diet, the arrest of miotic cataract produced by anticholineserases by cessation of drug therapy, and the arrest of traumatic cataract by sealing of the capsular perforation.
  • a traumatic anterior cortical cataract was followed for one year without evidence of progression. After laser ablation, this opacity showed partial clearing and this suggests that such lesions may be amenable to removal without the necessity for invasive surgical intervention.
  • the posterior subcapsular cataracts were stable prior to laser therapy and showed some clearing (although less effect due to difficulty in focusing the energy to the back of the lens) . In both cases no damage to the surrounding lenticular tissue or progression of opacification was noted. However, lens capsular scars were not treated and may still present a barrier to good vision.

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  • Vascular Medicine (AREA)
  • Optics & Photonics (AREA)
  • Surgery (AREA)
  • Engineering & Computer Science (AREA)
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Abstract

Procédé de photoablation au laser de tissu du cristallin comprenant les étapes de détermination d'un volume de tissu dont on doit pratiquer la photoablation et d'orientation d'un faisceau de laser infrarouge pulsé en direction dudit volume avec une quantité d'énergie efficace pour pratiquer la photoablation de la région déterminée sans provoquer d'endommagement important des régions tissulaires avoisinantes. On dirige d'abord le faisceau laser vers un point focal situé au niveau ou au-dessous d'une surface antérieure du cristallin et on déplace le point focal en direction de la surface antérieure du cristallin, ou on l'éloigne de celle-ci, de manière à effectuer l'ablation du volume déterminé. Le laser est, de préférence, un laser Nd:YLF fonctionnant à une fréquence de 1053 nanomètres environ et à un débit de répétition d'impulsions de 1000 Hertz environ avec une largeur d'impulsion d'environ 60 picosecondes. Chaque impulsion possède une énergie de 30 microjoules environ. Le laser fonctionne avec un diamètre de faisceau focalisé de 20 microns environ et selon une zone 'zone d'effet' non supérieure à 50 microns environ. Le procédé permet de corriger la myopie, l'hypermétropie ou la presbytie, ainsi que de supprimer la cataracte incipiente.
PCT/US1994/008835 1993-08-06 1994-08-03 Procede de photoablation au laser de tissu du cristallin WO1995004509A1 (fr)

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US08/103,089 1993-08-06
US08/103,089 US6322556B1 (en) 1991-10-30 1993-08-06 Method of laser photoablation of lenticular tissue for the correction of vision problems

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WO2004105660A1 (fr) * 2003-06-02 2004-12-09 Carl Zeiss Meditec Ag Appareil et procede permettant de realiser des interventions chirurgicales ophtalmologiques a l'aide d'un laser femtoseconde a fibres
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